TRISS Child Survey

Child Inpatient Satisfaction Survey

RCS Number: DD-HA (A) 2076

Survey Instructions

• Answer each question by marking the box to the left of your answer.

• You are sometimes told to skip over some questions in this survey. When this happens you will see an arrow with a note that tells you what question to answer next, like this:

 Yes

 No  If No, Go to Question 1

OMB CONTROL NUMBER: XXXX-XXXX

OMB EXPIRATION DATE: XX/XX/XXXX

AGENCY DISCLOSURE NOTICE

The public reporting burden for this collection of information, [Insert OMB Control Number], is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters Services, at [email protected]. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

You may notice a number on the survey. This number is used to let us know if you returned your survey so we don't send you reminders.

Please answer the questions about the child and hospital named in the cover letter. Do not include any other hospital stays in your answers.

WHEN YOUR CHILD WAS ADMITTED

TO THIS HOSPITAL

1. Was your child born during this hospital stay?

 Yes  If Yes, Go to Question 14

 No

2. For this hospital stay, was your child admitted through this hospital’s Emergency Room?

 Yes

 No  If No, Go to Question 5

3. Were you in this hospital’s Emergency Room with your child?

 Yes

 No  If No, Go to Question 5

4. While your child was in this hospital’s Emergency Room, were you kept informed about what was being done for your child?

 Yes, definitely

 Yes, somewhat

 No

5. During the first day of this hospital stay, were you asked to list or review all of the prescription medicines your child was taking at home?

 Yes, definitely

 Yes, somewhat

 No

6. During the first day of this hospital stay, were you asked to list or review all of the vitamins, herbal medicines, and over-the-counter medicines your child was taking at home?

 Yes, definitely

 Yes, somewhat

 No

YOUR CHILD’S CARE AFTER ADMISSION

TO THIS HOSPITAL

Do not include care received in the Emergency Room for the rest of the survey.

7. Is your child able to talk with nurses and doctors about his or her health care?

 Yes

 No  If No, Go to Question 14

yOUR CHILD’S EXPERIENCE WITH NURSES

The next questions ask about your child’s experience during this hospital stay. You will be asked about your own experience during this hospital stay in later questions.

8. During this hospital stay, how often did your child’s nurses listen carefully to your child?

 Never

 Sometimes

 Usually

 Always

9. During this hospital stay, how often did your child’s nurses explain things in a way that was easy for your child to understand?

 Never

 Sometimes

 Usually

 Always

10. During this hospital stay, how often did your child’s nurses encourage your child to ask questions?

 Never

 Sometimes

 Usually

 Always

YOUR CHILD’S EXPERIENCE WITH DOCTORS

11. During this hospital stay, how often did your child’s doctors listen carefully to your child?

 Never

 Sometimes

 Usually

 Always

12. During this hospital stay, how often did your child’s doctors explain things in a way that was easy for your child to understand?

 Never

 Sometimes

 Usually

 Always

13. During this hospital stay, how often did your child’s doctors encourage your child to ask questions?

 Never

 Sometimes

 Usually

 Always

YOUR EXPERIENCE WITH NURSES

14. During this hospital stay, how often did your child’s nurses listen carefully to you?

 Never

 Sometimes

 Usually

 Always

15. During this hospital stay, how often did your child’s nurses explain things to you in a way that was easy to understand?

 Never

 Sometimes

 Usually

 Always

16. During this hospital stay, how often did your child’s nurses treat you with courtesy and respect?

 Never

 Sometimes

 Usually

 Always

YOUR EXPERIENCE WITH DOCTORS

17. During this hospital stay, how often did your child’s doctors listen carefully to you?

 Never

 Sometimes

 Usually

 Always

18. During this hospital stay, how often did your child’s doctors explain things to you in a way that was easy to understand?

 Never

 Sometimes

 Usually

 Always

19. During this hospital stay, how often did your child’s doctors treat you with courtesy and respect?

 Never

 Sometimes

 Usually

 Always

YOUR EXPERIENCE WITH PROVIDERS

20. A provider in the hospital can be a doctor, nurse, nurse practitioner, or physician assistant. During this hospital stay, how often were you given as much privacy as you wanted when discussing your child’s care with providers?

 Never

 Sometimes

 Usually

 Always

21. Things that a family might know best about a child include how the child usually acts, what makes the child comfortable, and how to calm the child’s fears. During this hospital stay, did providers ask you about these types of things?

 Yes, definitely

 Yes, somewhat

 No

22. During this hospital stay, how often did providers talk with and act toward your child in a way that was right for your child’s age?

 Never

 Sometimes

 Usually

 Always

23. During this hospital stay, how often did providers keep you informed about what was being done for your child?

 Never

 Sometimes

 Usually

 Always

24. Tests in the hospital can include things like blood tests and x-rays. During this hospital stay, did your child have any tests?

 Yes

 No  If No, Go to Question 26

25. How often did providers give you as much information as you wanted about the results of these tests?

 Never

 Sometimes

 Usually

 Always

YOUR CHILD’S CARE IN THIS HOSPITAL

26. During this hospital stay, did you or your child ever press the call button?

 Yes

 No  If No, Go to Question 28

27. After pressing the call button, how often was help given as soon as you or your child wanted it?

 Never

 Sometimes

 Usually

 Always

28. During this hospital stay, was your child given any medicine?

 Yes

 No  If No, Go to Question 30

29. Before giving your child any medicine, how often did providers or other hospital staff check your child’s wristband or confirm his or her identity in some other way?

 Never

 Sometimes

 Usually

 Always

30. Mistakes in your child’s health care can include things like giving the wrong medicine or doing the wrong surgery. During this hospital stay, did providers or other hospital staff tell you how to report if you had any concerns about mistakes in your child’s health care?

 Yes, definitely

 Yes, somewhat

 No

31. During this hospital stay, did your child have pain that needed medicine or other treatment?

 Yes

 No  If No, Go to Question 33

32. During this hospital stay, did providers or other hospital staff ask about your child’s pain as often as your child needed?

 Yes, definitely

 Yes, somewhat

 No

THE HOSPITAL ENVIRONMENT

33. During this hospital stay, how often were your child’s room and bathroom kept clean?

 Never

 Sometimes

 Usually

 Always

34. During this hospital stay, how often was the area around your child’s room quiet at night?

 Never

 Sometimes

 Usually

 Always

35. Hospitals can have things like toys, books, mobiles, and games for children from newborns to teenagers. During this hospital stay, did the hospital have things available for your child that were right for your child’s age?

 Yes, definitely

 Yes, somewhat

 No

WHEN YOUR CHILD LEFT THIS HOSPITAL

36. As a reminder, a provider in the hospital can be a doctor, nurse, nurse practitioner, or physician assistant. Before your child left the hospital, did a provider ask you if you had any concerns about whether your child was ready to leave?

 Yes, definitely

 Yes, somewhat

 No

37. Before your child left the hospital, did a provider talk with you as much as you wanted about how to care for your child’s health after leaving the hospital?

 Yes, definitely

 Yes, somewhat

 No

38. Before your child left the hospital, did a provider tell you that your child should take any new medicine that he or she had not been taking when this hospital stay began?

 Yes

 No  If No, Go to Question 41

39. Before your child left the hospital, did a provider or hospital pharmacist explain in a way that was easy to understand how your child should take these new medicines after leaving the hospital?

 Yes, definitely

 Yes, somewhat

 No

40. Before your child left the hospital, did a provider or hospital pharmacist explain in a way that was easy to understand about possible side effects of these new medicines?

 Yes, definitely

 Yes, somewhat

 No

WHEN YOUR CHILD LEFT THIS HOSPITAL

As a reminder, please answer the questions about the child and hospital named in the cover letter. Do not include any other hospital stays in your answers.

41. Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital possible, what number would you use to rate this hospital during your child’s stay?

 0 Worst hospital possible

 1

 2

 3

 4

 5

 6

 7

 8

 9

 10 Best hospital possible

42. Would you recommend this hospital to TRICARE-eligible friends or family?

 Definitely no

 Probably no

 Probably yes

 Definitely yes

ABOUT YOUR CHILD

43. In general, how would you rate your child’s overall health?

 Excellent

 Very good

 Good

 Fair

 Poor

44. Is your child of Hispanic or Latino origin or descent?

 Yes, Hispanic or Latino

 No, not Hispanic or Latino

45. What is your child’s race? Mark all that apply.

 White

 Black or African American

 Asian

 Native Hawaiian or other Pacific Islander

 American Indian or Alaska Native

 Other

ABOUT YOU

46. How are you related to the child? Do not include personally identifiable information.

 Mother

 Father

 Grandmother

 Grandfather

 Other relative or legal guardian

 Someone else

Please print:

47. What is your age?

 Under 18

 18-24

 25-34

 35-44

 45-54

 55-64

 65-74

 75 and older

48. What is the highest grade or level of school that you have completed?

 8^th grade or less

 Some high school, but did not graduate

 High school graduate or GED

 Some college or 2-year degree

 4-year college graduate

 More than 4-year college degree

COMMENT

Please think about your child’s stay at the hospital named on the cover letter. Please answer this additional question about that stay. Do not include personally identifiable information.

49. What could we have done to improve this hospital stay?

THANK YOU

Please return the complete survey in the postage-paid envelope.

TRICARE Inpatient Satisfaction Survey, c/o Survey Processing

Center/IPSOS, PO Box 5030, Chicago, IL 60680-9858

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